Instructions for Submitting Requests

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ALERT: This system lets you as a patient or parent/guardian request that medical records be directed to a designated third party. You will not be able to access those records yourself. Only the third party will be able to access them through a secure website. If you prefer to access the records yourself and then direct them to a third party in whatever way you wish, please click here to use the 48-hour Quick Release short form for Comprehensive Pain Specialists.

What You Need to Get Started

1. The name, address, and fax number of the third party to whom you are directing your records.
2. The patient's valid driver's license or other valid state-issued ID.
3. A credit card to make payment
4. If you have the legal authority to make healthcare decisions for a patient as a healthcare trustee/conservator, healthcare proxy, or medical/healthcare power of attorney, you must upload three items: (a) the patient’s driver’s license/ID, (b) YOUR OWN Driver’s License/ID, AND (c) official documentation of your authority to make healthcare decisions for the patient. NOTE: A financial power of attorney is not acceptable. If you cannot provide ALL required items, the patient must place his or her own request.

Please have these items handy before you start!

Important - Please Read!

• To ensure patient security, we do not fax or mail paper records. We use the third party's fax number only to send a notification to the third party to go online to access the requested records securely.
• We cannot control when or if the third party listed on your request will access your records on our secure website. You are solely responsible for any and all follow-up with the third party. If you would rather access your records yourself and direct them to a third party in whatever way you wish, please click here to use the 48-hour Quick Release short form for Comprehensive Pain Specialists to have your records released directly to you.
You will be required to pay $25.00 for the processing of your request that is mailed to the third party.
• THERE ARE NO REFUNDS FOR ANY REASON WHATSOEVER.

NOTE: Third parties are not eligible to use this form to request records from Comprehensive Pain Specialists. Only patients or parents/guardians of patients are eligible to request records using this form.

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